Abstract

Women with borderline personality disorder have conflictual interpersonal
relations that may extend to disrupted patterns of interaction with their
infants.

Aims

To assess how women with borderline personality disorder engage with their
12 to 18-month-old infants in separation–reunion episodes.

Method

We videotaped mother–infant interactions in separation–reunion
episodes of the Strange Situation test. The mothers were women with borderline
personality disorder, with depression, or without psychopathological disorder.
Masked ratings of maternal behaviour were made with the Atypical Maternal
Behavior Instrument for Assessment and Classification.

Results

As predicted, a higher proportion (85%) of women with borderline
personality disorder than women in the comparison groups showed disrupted
affective communication with their infants. They were also distinguished by
the prevalence of frightened/disoriented behaviour.

Individuals with borderline personality disorder have severely troubled
interpersonal relations. To date there has been little research on how mothers
with this diagnosis relate to their infants, and whether any difficulties in
mother–infant communication might have untoward consequences for the
infants’ development. Such study is important not only for identifying
mother–infant dyads at risk and for informing intervention, but also for
shedding light on the patterns of moment-to-moment interpersonal relatedness
to which women with borderline personality disorder are prone when facing
stressful circumstances such as may occur during childrearing.

Background to the study

Borderline personality disorder and interpersonal relations

The condition of borderline personality disorder is one of the more
distinctive psychiatric syndromes of adulthood. According to
DSM–III–R, the diagnostic approach employed at the time the study
began, individuals are said to have borderline personality disorder when they
meet five out of eight diagnostic criteria: a pattern of intense, unstable
relationships; impulsiveness in at least two areas that are potentially
self-damaging; affective instability; inappropriate, intense anger or lack of
control of anger; recurrent suicidal threats or self-mutilating behaviour;
marked and persistent identity disturbance; chronic feelings of emptiness or
boredom; and frantic efforts to avoid real or imagined
abandonment.1
Although there is tentative evidence that temperamental factors such as
impulsive aggression and affective instability may act as risk factors for the
disorder, there is, as Posner et al conclude from reviewing their own
and others’ research, ‘currently no strong evidence that BPD
[borderline personality disorder] is
heritable’.2
Much stronger evidence suggests that environmental factors such as child
sexual abuse and other family influences such as maternal overinvolvement and
inconsistency may have a role in its
pathogenesis.3,4

The condition of borderline personality disorder is of special interest and
importance for the study of mother–infant relations. First, clinical
experience as well as more formal research suggests that individuals who have
this pattern of emotional and relationship difficulties also have
characteristic and potentially disturbing ways of relating to other people at
the level of moment-to-moment interactions. For example, Hobson et al
reported a controlled study that demonstrated how, compared with a group of
women with dysthymia, those with borderline personality disorder tended to
show forms of relatedness to a psychotherapist that entailed clear or subtle
indications of locked-in hostility and intense, idealising or denigrating
exchanges.5 If such
patterns of relatedness are a feature of these individuals’ relations
with their infants, there might be serious implications for the
children’s development. Second, there is evidence from controlled
studies employing the Adult Attachment Interview that women with borderline
personality disorder tend to be ‘enmeshed’ in representations of
their early attachments, and perhaps especially prone to ‘confused,
fearful and overwhelmed’ states of mind, as well as being unresolved
with respect to trauma and
loss.6–9
There is evidence that these attachment-related characteristics may influence
mothers’ relations with their infants, and in the case of unresolved
trauma, predispose to the kinds of ‘frightened/frightening’
behaviour thought to increase the likelihood of disorganised infant
attachments.10,11
In addition, a recent study involving masked ratings of Adult Attachment
Interviews in groups of women with borderline personality disorder or
depression suggested that the group with personality disorder had a high
prevalence of hostile/helpless states of
mind,12 conflictual
states in mothers that have been associated with infant disorganised
attachment in
offspring.13
Therefore there is much to be gained from studying mothers with this disorder
as they relate to their infants in the early months of life.

Maternal psychopathology and mother–infant relations

There is evidence that various forms of maternal psychopathology may be
associated with patterns of mother–infant interaction that have an
impact on infant development. The most extensive body of literature (e.g.
Murray &
Cooper)14 concerns
the effects of maternal depression, where there are now several reports of
negative affect and insensitivity in mother–infant interactions among
women with depression. Yet there has been little research of this type
involving women with borderline personality disorder. In the first study of
this kind, Crandell et al reported that such mothers were ‘
intrusively insensitive’ in face-to-face play with their
2-month-old
infants.15 In
response to a maternal still-face challenge, infants of these mothers showed
more dazed looks and more looks away from the mother than did infants of women
without borderline personality disorder, and they were relatively depressed in
mood subsequently.

A second study provides the immediate background to the present
investigation. Hobson et al assessed 12-month-old infants of women
with and without borderline personality disorder in three settings: first,
when the infants faced an initially unresponsive (still face) stranger who
subsequently tried to engage the infant in a game of give-and-take; second, in
the standard test of mother–infant attachment patterns (the Strange
Situation);16 and
third, a situation in which mothers were requested to teach their infants to
play with miniature figures and a toy
train.17 In
accordance with predictions, there were three sets of group differences.
Towards the stranger, the infants of women with borderline personality
disorder showed lower levels of ‘availability for positive
engagement’, lower ratings of ‘behaviour organisation and mood
state’ and a lower proportion of interpersonally directed looks that
were positive. Second, a higher proportion of infants from the personality
disorder group (8 out of 10, v. 6 out of 22 mothers with no
psychopathological diagnosis) were categorised as ‘disorganised’
in attachment, and the remaining two mother–infant pairs in this group
also showed some signs of disorganisation. Disorganised attachment is
characterised by fearful, odd or contradictory forms of infant behaviour when
reuniting with a parent, and is associated with a range of behavioural
difficulties later in childhood such as hostile–aggressive relations
with
peers.18–20
Third, the women with personality disorder were rated as more intrusively
insensitive towards their infants in the teaching task. The study also yielded
evidence that individual differences in infant–stranger relations and
organised/disorganised infant attachment could not be ascribed to maternal
intrusive insensitivity per se. As Hobson et al
concluded:

‘... motherswith borderline personality disorder tend to be
intrusively insensitive, but insofar as maternal relatedness is causally
related to infant sociability, it appears to be the manner or quality of this
intrusive form of relatedness that is most important for infant
development’.17

Especially given that intrusiveness had been assessed in a single
(prompted) teaching task rather than in natural interactions, it remained to
apply more refined measures of the qualities of interpersonal relatedness that
characterised the mother–infant interactions. In the previous study the
Strange Situation test was used to evaluate the infants’ patterns of
relatedness to their mothers and with the advent of an appropriately focused
measure of maternal behaviour, we now had the opportunity to rate maternal
contributions to the videotaped mother–infant exchanges in this
situation.

Our hypothesis was that in virtue of relatively specific configurations of
mental representations of relations with significant others (or what
psychoanalysts call ‘internal object relations’), women with
borderline personality disorder are prone to relate to other people –
and in the present context, their infants – with particular intense,
inconsistent and often self-oriented styles of
engagement.17
Anticipating that these patterns of dysregulated affective and communicative
exchange were likely to be reflected in ratings on the Atypical Maternal
Behavior Instrument for Assessment and Classification (further information
available from the authors). We made a single, directional prediction: that
compared with two groups of mothers, one with depression and the other without
a psychiatric diagnosis, a higher proportion of mothers with borderline
personality disorder would manifest disrupted affective communication with
their infants.

Method

Measure of maternal relatedness

The Atypical Maternal Behavior Instrument for Assessment and Classification
(AMBIANCE) was developed by Lyons-Ruth and her colleagues to code disrupted
forms of maternal affective communication with an
infant.20 It
delineates unusual aspects of maternal responsiveness that are not adequately
described in generalised coding systems for warmth or sensitivity, by focusing
upon the breakdown of affective communication and the disruptive effects of
unintegrated fear, hostility and anxiety. The measure has yielded consistent
results across samples varying widely in socioeconomic status. A recent
meta-analysis has confirmed the validity of the measure in relation to infant
disorganised attachment (r = 0.35, n = 384) and to maternal
unresolved loss or trauma on the Adult Attachment Interview (r =
0.20, n =
311).21 In
test–retest studies the AMBIANCE measure exhibited significant stability
over periods ranging from 8 months to 5 years, covering a range of infant ages
from 4 months to 6 years (r = 0.56, n =
203).22 Lyons-Ruth
et al reported that disrupted maternal communication on this measure
mediated the relation between hostile/helpless parental states of mind with
respect to attachment, and infant
disorganisation.13
Finally, Grienenberger et al reported that among 45 women with
infants aged 10–14 months, high AMBIANCE scores were inversely
correlated with a measure of maternal reflective
functioning.22
Therefore there is substantial evidence for the validity and stability of this
measure, as well as its applicability to the phenomena and range of infant
ages and socioeconomic status we wished to study.

Participants

There are difficulties in recruiting adequate samples of women with
borderline personality disorder together with a comparison group of women with
other psychopathological disorders during the relatively brief times when they
are parenting an infant. In order to overcome these difficulties, we combined
data from two existing cohorts of mothers and infants for whom both parenting
behaviour and Axis II data were available. The first cohort (see Hobson et
al for full
details)17
comprised 10 mothers with borderline personality disorder and a control group
of 22 mothers who had no clinical feature of borderline personality disorder,
nor other history of psychiatric disorder, and who were similar in age,
ethnicity, social class, marital status and education
(Table 1). In five cases care
was shared, but mothers were always among the primary caregivers.

Screening of potential participants included the collection of demographic
data and administering the questionnaire version of the Structured Clinical
Interview for DSM–III–R Non-Patient Version
(SCID–NP),23
and a questionnaire version of the SCID overview and module A, focusing on
mood syndromes, and module B/C (the ‘psychotic screen’). Women who
met the criteria for borderline personality disorder and no other disorder
were invited for interview and were given the Structured Clinical Interview
for DSM–III–R Personality Disorders (SCID–II)
interview,24
supplemented with the interview version of the SCID overview and modules A and
B/C. Only women meeting the diagnostic criteria for borderline personality
disorder and no other diagnostic category were recruited for the personality
disorder group. Women were accepted into the control group provided that on
screening and interview they showed no feature of borderline personality
disorder and did not meet diagnostic criteria for any other
DSM–III–R disorder, either current or past.

The second cohort of mothers and infants were participants in a
longitudinal study of attachment and mother–infant interaction in 65
families at or below poverty level (see Lyons-Ruth et al for full
details).25 When
the children were 18 months old, their mothers received diagnostic screening
for Axis I disorders with the semi-structured Diagnostic Interview
Schedule.26 Sixteen
mothers had no psychiatric diagnosis, and 27 mothers met criteria for
depressive disorder (major depression or dysthymia) with or without anxiety
disorder, but without other psychiatric comorbidity. Twenty-two mothers with
other diagnoses were excluded from the sample for the purposes of the present
study.

A diagnostic screen for Axis II disorders was not available at the time of
the infant study. When the infants had grown and reached 20 years of age,
their mothers were administered the SCID–II for diagnosis of personality
disorders. For the study reported here, all women with any personality
disorder were excluded from the groups previously diagnosed with depression,
and those previously without diagnosis. The rationale was that interpersonal
aspects of borderline personality disorder are relatively stable over
time,27 and were
likely to have been present earlier when these women’s children were in
infancy. The final groups from this sample were 15 mothers with depression, 9
mothers without a diagnosis and a third group comprising 3 mothers who met
criteria for borderline personality disorder on the SCID–II at 20-year
follow-up. It should be noted that if any women in the depression group had
met criteria for borderline personality disorder at the time of
mother–infant testing but did not meet criteria at the 20-year
follow-up, this would introduce a conservative bias into testing the predicted
group differences. In three cases, care was shared with grandmothers but in
all cases the mother was the primary caregiver.

Combining both study cohorts yielded a final sample of 13 mothers with a
diagnosis of borderline personality disorder, 15 mothers with a diagnosis of
depression and 31 mothers with no psychiatric diagnosis. Although the two
samples differed in socioeconomic status and infant age, our dependent
variable, the AMBIANCE measure, has been shown to be stable over this range of
participant characteristics as noted
earlier.21

Measures

Maternal disrupted affective communication

The Strange Situation procedure for assessing infant attachment behaviour
under the stress of two separation–reunion episodes was conducted and
videotaped according to standard procedures in both cohorts (see Hobson et
al17 and
Lyons-Ruth et
al25 for
details). Maternal interactive behaviour over the course of the Strange
Situation procedure was rated from these videotapes using AMBIANCE. There are
two stages to the rating procedure: first, counts are made of particular forms
of disrupted maternal affective communication when mother and baby are
together; second, based on both the frequency and seriousness of the observed
forms of disrupted communication, a rating is given on a seven-point scale for
overall level of disrupted affective communication. Parents rated at 5 or
above on the scale are classified as disrupted in parent–infant
communication. Since our single prediction concerned the disrupted
classification, we shall consider this first.

Partial criteria for a score of 5 are as follows: the parent displays
persistent mixed affective signals, persistent errors in responding to infant
needs, intrusive behaviour, confusion, disorientation, lack of responsiveness,
and/or role-reversing behaviour with the infant. The parent often attempts to
engage with the infant but may have a difficult time diverting from [her] own
style or needs, particularly when attachment affects are heightened as at
reunions.

A score of 6 represents a predominance of disrupted communication in which
the parent’s responses frequently fail to match the infant’s
signalling. Relevant behavioural features include ‘Demonstrates
significant difficulty around most physical contact with the infant’, ‘
Affective response to the infant may include indirect (or masked)
expression of negative affect, a lack of affect, or inauthentic affect’,
and ‘Parent’s response to the infant may include confusion,
disorientation, fear, or unusual voice quality’.

A score of 7 is given when, in addition to the above, there is almost no
positive ameliorating behaviour.

Prior to rating the overall level of disrupted communication, the coder
reviewed the videotape and made a count of instances of the following forms of
maternal behaviour, using itemised examples in the coding manual:

affective communication errors, coded when the parent gives contradictory
affective signals to the infant (e.g. using a sweet voice with a derogatory
message or with a threatening posture) or makes inadequate or inappropriate
responses to the infant’s signals (e.g. fails to comfort a distressed
infant);

role confusion, coded when the mother calls the infant’s attention to
herself in ways that override or ignore the infant’s cues (e.g. asking
the infant for a kiss when the infant is distressed);

frightened/disoriented behaviour, as shown in fearful, hesitant or
deferential behaviour towards the infant (e.g. asking permission of the
infant) or as expressed in disoriented behaviour, including loss of affect and
movement (e.g. ‘freezing’), frenetic and uncoordinated overtures
toward the infant, or sudden and unusual shifts in voice tone;

negative–intrusive behaviour, either in physical interaction (e.g.
pulling the infant by the wrist) or in verbal communication (e.g. attributing
negative feelings or motivation to the infant, as in ‘He/she hates
me’);

withdrawing behaviour, as shown by creating physical distance from the
infant (e.g. directing the infant away from herself through the use of toys)
or creating verbal distance (e.g. interacting silently).

In both cohorts, the videotapes were rated by one of the originators of the
AMBIANCE measure (E.B.), who was unaware not only of participant diagnoses but
also of the overall nature and predictions of the study. Previously reported
interrater reliabilities involving this rater (n = 15) were as
follows: disrupted classification (κ = 0.73), overall level of disrupted
affective communication (κ = 0.93), frequencies for items on each of the
five dimensions (intraclass correlations)
0.73–0.84.20

The data from the mothers with borderline personality disorder in each
cohort were also comparable, although with only 3 such mothers in cohort 2,
statistical tests were not applied. The data for the 10 mothers with this
diagnosis in cohort 1 and the 3 mothers in cohort 2 were as follows: for
frequency counts of total disrupted behaviour, cohort 1 had a mean count of
35.6 (s.d. = 23.0, range 4–87), whereas in cohort 2 the counts were 14,
19 and 60; for levels of disrupted communication, in cohort 1 the mean score
was 4.8 (s.d. = 1.6, range 2–6) and in cohort 2 the scores were 5, 5 and
6. Eight participants with borderline personality disorder (80%) in cohort 1
and all three participants (100%) in cohort 2 were classified as having
disrupted communication. Given these similarities in AMBIANCE scores within
diagnostic categories across the two cohorts, data from the two studies were
combined to test for group differences.

Disrupted affective communication

Our single directional prediction was that compared with both comparison
groups (i.e. those with depression and those without diagnoses) a higher
proportion of the women with borderline personality disorder would manifest
disrupted affective communication with their infants (i.e. score 5 or above).
Eleven out of 13 (85%) of the women with borderline personality disorder, 7 of
the 15 women with depression (47%) and 13 of the 31 women without a formal
psychopathological diagnosis (42%) fell into the disrupted category
(χ2 = 6.97, P<0.05). Follow-up analyses revealed
that this difference was specific to the borderline personality disorder
group, in which there were more women classified as having disrupted
communication than in the group with depression (Fisher’s exact test,
P = 0.027, one-tailed), as well as those without psychopathological
disorder (Fisher’s exact test, P = 0.009, one-tailed). It is
noteworthy that the only two women with borderline psychopathology who were
not rated as above the threshold for disrupted affective
communication had infants who were rated as ‘disorganised’ by
Hobson et
al,17 raising
the likelihood that in these cases, too, mother–infant relations were
problematic.

There was complementary evidence for the prevalence of episodes of
disrupted communication among women with borderline personality disorder in
the counts of such behaviour across the procedures of the Strange Situation.
Here the respective data were as follows: for the borderline disorder group
the mean was 35.5 (s.d. = 22.5, range 4–87), for the group with
depression it was 17.7 (s.d. = 10.5, range 2–38) and for the group with
no diagnosis it was 19.3 (s.d. = 15.0, range 1–49);
F(2,56) = 4.92, P<0.05. Follow-up planned
comparisons revealed that the women in the borderline disorder group had
significantly higher scores than either those with depression (t(26)
= 2.59, P<0.05) or those without diagnoses (t(42) = 2.63,
P<0.05).

The results on each of the dimensions of the AMBIANCE are given in
Table 2, together with data
from a series of five 3 (group)×1 (AMBIANCE dimension) univariate
analyses of variance. The only significant main effect for diagnostic group
was on fearfulness/disorientation: F(2,56) = 5.66,
P<0.01, η2 = 0.17. Follow-up contrasts revealed
that frightened/disoriented behaviour was more frequent in the borderline
personality disorder group than in either the depression group (t(26)
= 2.25, P<0.05) or the group without diagnosis (t(42) =
3.16, P<0.01). Frightened/disoriented behaviour was rare among
women who did not have the diagnosis of borderline personality disorder, even
among those whose communication was judged to be disrupted.

Discussion

The results of this study illuminate the ways in which the interpersonal
psychopathology of borderline personality disorder is manifest in mothers
faced with the challenge of relating to their potentially needy and distressed
infants under the conditions of the Strange Situation test. As predicted, a
higher proportion of women with borderline personality disorder were
classified as showing disrupted affective communication than was the case for
women with depression or those without a psychiatric diagnosis. In addition,
these mothers were significantly more likely to exhibit fear/disorientation in
response to the infant’s attachment bids, a pattern strongly associated
with infant disorganised
attachment.28,29

Our study has two principal limitations. The first is that the groups were
constituted by combining two cohorts of mother–infant dyads who differed
with respect to the ages of the infants (approximately 12 months and 18 months
respectively) and demographic status (one of relatively high socioeconomic
status, and the other of low socioeconomic status and high at-risk status).
Three considerations offset the potential problems here. First, the AMBIANCE
data from each cohort of mothers without psychopathological diagnosis and of
mothers with borderline personality disorder were similar. Second, there is no
prime facie reason to suppose that the kinds of maternal disrupted
communication assessed through AMBIANCE should alter substantially, whether
mothers are relating to 12-month-old or 18-month-old
offspring.21 Third,
given the enhanced risks associated with economic stress, the higher mean
socioeconomic status of the women in the borderline disorder group compared
with those in the depression group would tend to decrease the chance of
finding the predicted group differences.

A further limitation is that insofar as the majority of the women with
borderline personality disorder lacked comorbidity, this group was not
necessarily representative of the broader range of individuals with this
diagnosis. Yet this also means that the findings were more likely to reflect
maternal characteristics associated with the diagnosis, rather than arising
from sources such as low socioeconomic status or comorbid conditions. It
remains open to question how far disrupted affective communication, and
fearful/disoriented behaviour in particular, might be prevalent among women
with psychiatric diagnoses other than borderline personality disorder or
depression.

Overall, these findings provide substantive support for the perspective
that individuals with borderline personality disorder who manifest clinical
features such as impulsivity, self-damaging behaviour and affective
instability also have troubled patterns of affective communication and
relatedness in their moment-to-moment interactions with significant
others.5,16
Separate lines of evidence also suggest that individuals with borderline
personality disorder are often confused, fearful and overwhelmed when
recalling their childhood
relationships;9 they
show lapses in their discourse or their reasoning when discussing losses or
traumatic
events;7,9
they describe caregivers in globally devalued terms and maintain unintegrated
hostile and helpless attitudes towards
them;9,12
and they are limited in their reflective
self-functioning.8
Such styles of thinking and feeling appear to have correspondence with these
individuals’ qualities of observed relations with other people,
including their infants. This is likely to be very significant for the high
prevalence of disorganised attachment also reported among infants of mothers
with borderline personality
disorder.17

It remains to be determined how far infant constitutional characteristics
might play a part in shaping these mother–infant relations. Although
there are likely to be mutual and transactional influences between maternal
and infant characteristics over the course of early development, our results
point to a maternal contribution to these dysregulated interactions. The
AMBIANCE coding system focuses on the caregiver’s responses to clear
infant cues and on the caregiver’s failure to take a parental role in
structuring the interaction with the infant, and these do not appear to be
driven by the infant’s behaviour. Moreover, a recent meta-analysis
reported that disrupted communication predicted infant disorganisation whether
or not it was coded concurrently in the Strange Situation or in an independent
play session.21
Therefore it is unlikely that the infant’s behaviour is driving the
mother’s disrupted communication. Given the evidence that disorganised
infant attachments prefigure aggressive behaviour problems into middle
childhood,19 and
that maternal disrupted communication is predictive of the infant growing up
to show dissociation in young
adulthood,30 there
appears to be a risk of the intergenerational transmission of disorder among
the children of women with borderline personality disorder.

The clinical implications of our findings are twofold. First, the results
suggest that we need to consider borderline personality disorder in terms of
the disturbances in interpersonal affective communication seen in individuals
who present with the syndrome. We might better understand these interpersonal
disturbances if we were to adopt a developmental perspective. Second, we need
to consider whether intervention might be indicated to support the mothers and
foster more optimal mother–infant relations.